Application for Mooring Permit / Mooring Waitlist - Hawaii

This "Application for Mooring Permit / Mooring Waitlist" is a part of the paperwork released by the Hawaii Department of Land & Natural Resources specifically for Hawaii residents.

The latest fillable version of the document was released on June 1, 2011 and can be downloaded through the link below or found through the department's forms library.

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APPLICATION FOR
MOORING PERMIT / MOORING WAITLIST
Division of Boating and Ocean Recreation
Department of Land and Natural Resources, State of Hawaii
1. PERMIT INFORMATION
OFFICE USE ONLY
Date:
Island ( one) :
Hawaii
Kauai
Lanai
Maui
Molokai
Oahu
q
q
q
q
q
q
/
/
4
Date Received:
Location:
Category:
Received By:
2. APPLICANT INFORMATION
Name (Last):
(First):
(M.I.):
Suffix:
q
q
Date of Birth:
Gender:
Female
Male
Occupation:
/
/
Employer:
Phone (business):
(home):
Email:
Apt #:
Mailing Address:
City:
State:
Zip:
Billing Address:
Apt #:
City:
State:
Zip:
3. VESSEL INFORMATION (If you have NOT yet purchased or registered your vessel, skip this step and proceed to section 6.)
q check if same as Applicant
's Name (Last):
(First):
(M.I.):
Suffix:
Owner
q
q
Date of Birth:
Gender:
Female
Male
Phone:
Co-owner
's Name (Last):
(First):
(M.I.):
Suffix:
q
q
Date of Birth:
Gender:
Female
Male
Phone:
/
/
Vessel Name:
Port of Registry:
q
Registration
q
Coast Guard Documentation
q
None
Documentation Type:
Registration or Doc. #:
Expiration Date:
/
/
Hull Manufacturer:
Year Built:
Length Overall:
(feet)
(inches)
Hull ID#:
Number of Hulls:
Length Over Deck:
(feet)
(inches)
Hull Color:
Cabin Color:
Draft of Vessel:
(feet)
(inches)
Top Deck Color:
Trim Color:
Beam of Vessel:
(feet)
(inches)
Mooring Permit or Mooring Waitlist, Revised: 06/2011
Page 1 of
4
APPLICATION FOR
MOORING PERMIT / MOORING WAITLIST
Division of Boating and Ocean Recreation
Department of Land and Natural Resources, State of Hawaii
1. PERMIT INFORMATION
OFFICE USE ONLY
Date:
Island ( one) :
Hawaii
Kauai
Lanai
Maui
Molokai
Oahu
q
q
q
q
q
q
/
/
4
Date Received:
Location:
Category:
Received By:
2. APPLICANT INFORMATION
Name (Last):
(First):
(M.I.):
Suffix:
q
q
Date of Birth:
Gender:
Female
Male
Occupation:
/
/
Employer:
Phone (business):
(home):
Email:
Apt #:
Mailing Address:
City:
State:
Zip:
Billing Address:
Apt #:
City:
State:
Zip:
3. VESSEL INFORMATION (If you have NOT yet purchased or registered your vessel, skip this step and proceed to section 6.)
q check if same as Applicant
's Name (Last):
(First):
(M.I.):
Suffix:
Owner
q
q
Date of Birth:
Gender:
Female
Male
Phone:
Co-owner
's Name (Last):
(First):
(M.I.):
Suffix:
q
q
Date of Birth:
Gender:
Female
Male
Phone:
/
/
Vessel Name:
Port of Registry:
q
Registration
q
Coast Guard Documentation
q
None
Documentation Type:
Registration or Doc. #:
Expiration Date:
/
/
Hull Manufacturer:
Year Built:
Length Overall:
(feet)
(inches)
Hull ID#:
Number of Hulls:
Length Over Deck:
(feet)
(inches)
Hull Color:
Cabin Color:
Draft of Vessel:
(feet)
(inches)
Top Deck Color:
Trim Color:
Beam of Vessel:
(feet)
(inches)
Mooring Permit or Mooring Waitlist, Revised: 06/2011
Page 1 of
4
Division of Boating and Ocean Recreation
Department of Land and Natural Resources
State of Hawaii
APPLICATION FOR MOORING PERMIT OR MOORING WAITLIST (
)
Continued
4. VESSEL TYPE AND PROPULSION (If you have NOT yet purchased or registered your vessel, skip this step and proceed to section 6.)
q
q
q
q
q
Vessel Type ( one):
Open Motorboat
Motor Vessel (more than 65)
Sailing Vessel
Houseboat
Runabout
4
q
q
q
q
Auxilary Powered Sailing Vessel
Cabin Motorboat
Thrillcraft
Dinghy or Skiff
q
q
q
Barge
Platform
Other:
Principle Use ( one):
q
Pleasure
q
Charter Fishing
q
Commercial Fishing
q
Commercial Passenger
q
Charter Bare Boat
4
q
q
q
q
q
Dealer
Manufacturer
Charter Sail
Water Taxi
Other Commercial:
q
q
q
q
Primary Propulsion Type ( one):
Power
Sail
None
Other:
4
q
q
q
q
q
q
If Power: Engine Type(s) ( one):
Outboard
Inboard
Outboard / Inboard
Manual
None
Other:
4
Engine Manufacturer:
Horsepower:
Number of Engines:
q
q
q
q
q
q
If Sail:
Rigging Type:
Sloop
Schooner
Three-Masted Schooner
Four-Masted Schooner
Ketch
Brig
q
q
q
q
q
q
q
q
Brigantine
Barque
Barquentine
Fully Rigged Ship
Snow
Yawl
Cutter
Clipper
Auxiliary Propulsion for Sail:
q
q
q
q
Engine Type(s) ( one):
Outboard
Inboard
Outboard / Inboard
None
4
Engine Manufacturer:
Horsepower:
Number of Engines:
q
q
q
q
Fuel Type ( one):
Gasoline
Diesel
Electric
Other (specify):
4
5. VESSEL PURCHASED INFO (If you have NOT yet purchased or registered your vessel, skip this step and proceed to section 6.)
I, the undersigned, ( one)
q
Purchased
q
Leased
q
Other (specify):
4
the aforementioned vessel on (date):
from:
The vessel described on this application is free of all liens, mortgages, or other encumbrances except as follows:
Provide the name or institution holding security interest.
Name (Last) or Institution:
Address:
City:
State:
Zip:
Name (Last) or Institution (if jointly held):
Address:
City:
State:
Zip:
6. DECLARATION OF HAWAII RESIDENCY
Proof of residency must be presented at Harbor office within seven (7) days of application submission. Failure to
present proof will result in automatic denial of the application and forfeiture of fees. Applicant will be required to
resubmit in person their application and documentation at a DoBOR office.
q
I claim legal residence in Hawaii
7. AGREEMENT & SIGNATURE
I agree to comply with the provisions of the Hawaii
Administrative Rules as promulgated by the Division of
/
/
Boating and Ocean Recreation applicable to this permit.
Signature of Applicant
Date
Mooring Permit or Mooring Waitlist, Revised: 06/2011
Page 2 of
4
PROOF OF HAWAII RESIDENCY
Division of Boating and Ocean Recreation
Department of Land and Natural Resources
State of Hawaii
1(a). APPLICANT RESIDENCY STATEMENT
Proof of residency must be presented at Harbor office within seven (7) days of application submission.
OFFICE USE ONLY
Failure to present proof will result in automatic denial of the application and forfeiture of fees. Applicant
Date Received:
will be required to resubmit in person their application and documentation at a DoBOR office.
Received By:
I, (print your full name)
, claim legal residence in the:
State of Hawaii -OR-
state & country of (specify):
.
q
q
1(b). APPLICANT INFORMATION
Name (Last):
(First):
(M.I.):
Suffix:
q
q
Date of Birth:
/
/
Gender:
Female
Male
Phone (h):
Phone (o):
q
q
Citizenship:
United State of America -OR-
Other country (specify):
q
q
q
Alien Only-Visa Status:
Student
Migrant
Other (specify):
Apt #:
Mailing Address:
Address Line 2:
Country:
City:
State:
Zip:
Apt #:
Primary Residence Address:
City:
State:
Zip:
2. FOR RESIDENT ADULTS ONLY
If you claim Hawaii as your legal residency, are 18 years old or over, or married, complete following section.
a. Length of residency in the State of Hawaii:
From:
/
/
b. Resident income tax returns (check & complete the pertinent portion).
q
(1)In the past 2 years, I filed State of Hawaii resident income tax returns.
Name under which I filed the State of Hawaii resident income tax returns (full name):
.
-OR-
q
(2)In the past 2 years, I filed resident income tax returns in (state)
.
-OR-
q
(3)I did NOT file resident income tax returns in any State or County during the past 2 years.
c. Registered to vote in the State of
.
d. Last voted in the State of
in the year
.
q
q
e. Do you currently own a car registered in the State of Hawaii?
Yes
No. If Yes, write the license plate number:
Proof of Hawaii Residency, Revised: 03/2011
Page 3 of
4
Division of Boating and Ocean Recreation
Department of Land and Natural Resources
State of Hawaii
PROOF OF HAWAII RESIDENCY(
)
Continued
2. FOR RESIDENT ADULTS ONLY (Continued)
f. Describe time periods when you were out of the State of Hawaii during the last 12 months (include dates & reasons; if none, so indicate).
g. Names of employer(s) for the past three years (include addresses and dates of employment; if none, so indicate).
-
-
-
h. Do you have close relatives living in the state of Hawaii?
q
Yes.
q
No.
q
q
q
q
q
If Yes, indicate (check all that apply):
Mother
Father
Brother(s)
Sister(s)
Other (specify):
i. Do you currently own or lease residential property in the State of Hawaii?
Yes.
No.
q
q
If Yes, do you live on the property?
Yes.
No. What is the address of the property?
q
q
Leased / owned since (year):
j. Do you currently own a business in the State of Hawaii?
q
Yes.
q
No. If Yes, what is the name and address of the business?
Last year in which you paid Hawaii General Excise Tax for your business:
k. Have you ever been licensed by the State of Hawaii for practise of some professional occupation?
q
Yes.
q
No.
If Yes, what occupation?
Last year licensed:
l. Are you a member of any volunteer organizations in Hawaii?
Yes.
No. If Yes, please list:
q
q
m. I am a resident and intend to continue residency in the State of Hawaii, and I am:
18 years of age or older
under 18 years of age.
q
q
n. Indicate on a separate sheet any other information which you believe would aid in establishing your claim of legal residence in Hawaii.
3. CERTIFICATION & SIGNATURE
I certify that the answers and responses in this application are true to the best of my knowledge, and I undennstand that misrepresentation
of any fact upon this form is a violation of the Small Boat Harbors Regulations, Department of Land and Natural Resources, State of
Hawaii and may be cause for the rejection of this application and revocation of use permits. I hereby authorize the persons, agencies or
institutions identified on the form to release information to the Department of Land and Natural Resources, State of Hawaii to confirm my
responses.
/
/
Printed Name of Applicant
Signature of Applicant
Date
Proof of Hawaii Residency, Revised: 03/2011
Page 4 of
4

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